Application Form

Applicant Information
Applicants are considered for all positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, I or any other prohibited basis of discrimination, as provided under applicable state and federal law.
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone #*
(including area code)
General Work History
Have You Ever Been Employed By Friendship Haven, Inc.?*
- Yes
- No
If yes, under what name?
Date Last Worked
Position Held
Reason For Departure
Position For Which You Are Applying?*
Expected Wage
When Can You Start?
Hours You Would Like To Work Per Week?*
Shift Preference*
- Morning
- Afternoon
- Night
Are You Willing To Work Weekends?*
- Yes
- No
Are You Willing To Work Holidays?*
- Yes
- No
What/Who Prompted You To Apply Here?
List Any Relatives That Work Here
If Under 16, Can You Obtain a Permit To Work?
- Yes
- No
- Not Applicable
Are you physically and mentally able to perform the essential functions of the job for which you are applying with or without reasonable accomodation?*
- Yes
- No
If No, Please Explain
Do you have a record of founded child or dependent adult abuse in this state or any other state?*
- Yes
- No
If Yes, Please Explain
Have you ever been convicted of a crime, in this state or any other state?*
- Yes
- No
If Yes, Please Explain
A conviction record will not necessarily be a bar to employment. Factors, such as age and timing of offense, seriousness and nature of the violation and rehabilitation will be taken into account.
Do you have a nursing license?*
- Yes
- No
Type of License
- RN
- LPN
Registration #
State
Are you a certified nursing assistant?*
- Yes
- No
If hired, can you furnish proof that you are eligible to work in the United States?*
- Yes
- No
If unsure of the documents needed to prove eligibility to work in the U.S., we will be happy to explain the legal requirements.
If No, Please Explain
Educational History
Highest Level of Education Completed*
- Grade School
- High School
- College
- Graduate School
- Business/Technical
High School*
High School/Location Course/Major Graduated (Yes/No)
College
College/Location Course/Major Degree (Yes/No)
Business, Technical, Night or Correspondence/Location
School/Location Course/Major Degree (Yes/No)
Employment History
Please begin with the most recent.
May we contact your present employer?*
- Yes
- No
Employer*
Company Telephone Address Job Title Supervisor Job Description Salary Reason for Leaving Start Date End Date
Employer
Company Telephone Address Job Title Supervisor Job Description Salary Reason for Leaving Start Date End Date
Employer
Company Telephone Address Job Title Supervisor Job Description Salary Reason for Leaving Start Date End Date
References
Please list names, addresses and telephone numbers of the three persons other than relatives and employers with whom you are acquainted.
Reference #1*
Name How do you know them? Address Phone #
Reference #2*
Name How do you know them? Address Phone #
Reference #3*
Name How do you know them? Address Phone #
Additional Information
Comments/Questions
Use this space to provide any additional information that might be useful in considering you for employment.
Attach an Optional Résumé
Accepted file types: pdf, docx.
(PDF or Word Doc)
Attach an Optional Cover Letter
Accepted file types: pdf, docx.
(PDF or Word Doc)